Healthcare Provider Details

I. General information

NPI: 1023375300
Provider Name (Legal Business Name): JON WILLIAM MARES D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 N HIGHWAY 190
COVINGTON LA
70433-5364
US

IV. Provider business mailing address

PO BOX 3370
COVINGTON LA
70434-3370
US

V. Phone/Fax

Practice location:
  • Phone: 985-867-8585
  • Fax: 985-867-3644
Mailing address:
  • Phone: 985-867-8585
  • Fax: 985-867-3644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036.151545
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberQ6769
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: